Teaching hospitals are national assets that must urgently be taken out of the hands of provincial governments and doctors must exit the central bargaining chamber where their negotiating power is reduced to that of 'labourers and sweepers'.

These are among the views of the newly appointed President of the Health Professions Council of South Africa (HPCSA), Professor Sam Mokgokong, a ground-breaking local neurosurgeon and distinguished academic.

Interviewed by Izindaba last month, Mokgokong was unusually outspoken for an HPCSA President, displaying an independence rarely seen in his predecessor, Professor Nicky Padayachee, now the national Deputy Director-General of Health.

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Mokgokong, best known internationally as a specialist and lead surgeon in separating craniopagus Siamese twins, was pressed on a number of issues that have historically angered doctors and distanced them from the HPCSA. Doctors, especially those in the public sector, are cynical about the HPCSA's supposed autonomy and its incongruous track record when it comes to 'protecting the public and guiding the professions'. While stressing that his views did not necessarily represent those of the HPCSA, Mokgokong said that they would inform much of his tenure - which happens to coincide with a sea-change in health leadership generally in South Africa. He described complaints of under-representation of doctors at Council level as 'worth probing'. The Medical and Dental Professions Board (MDPB) has up to five times the registered membership of the 11 other HPCSA disciplines (50 000 versus between 4 and 10 000 members per board).

Skewed numbers torpedo doctor vote

There are, however, only 3 MDPB members on the 32-person Council versus one or two from each of the other boards. In terms of the Health Professions Amendment Act, the Health Minister appoints 11 'others' consisting of 9 community representatives, a legal advisor and a health department official. His peers in education and defence appoint one person each, with three more coming from higher education. This ministerial voting power in the HPCSA was a source of great MDPB consternation when the law was amended, with doctors claiming they had been sidelined professionally and deeply distrusting the motives of the then controversial health minister, the late Dr Manto Tshabalala-Msimang.1

Mokgokong disagreed with moves by the medical profession to have their own standalone council, saying the current set-up was actually more democratic than in the past. 'The [then] SA Medical and Dental Council was called a doctors' club because it was almost exclusively run by doctors, so if patients wanted a case against them, the perception was that nothing was done, irrespective of the merits of the case,' he argued.

He said that on matters of discipline, education and training standards, each board's decision was 'almost final', while Council's role was to manage the professions, work out the budgets, audit risk and play an administrative role.

Viewed from a 'functions and litigation' perspective, however, 80% of the HPCSA's activities centred on doctors (and dentists), 'so they have a point; in Council as it stands, they are under-represented. The new Council must look at this and if we agree, take it to the health minister to change,' he conceded.

Mokgokong intimated that on volatile issues like the 2009 public sector doctors' strike (centering on the occupation-specific dispensation salary structure) he would be more likely to 'speak up' to the health minister about working conditions. Doctors at the time, 76 of whom (all from KwaZulu-Natal) were notified by the HPCSA of preliminary disciplinary hearings for allegedly contravening their Hippocratic Oath by striking, were incensed by the Council's lack of censure of often dysfunctional provincial and national health departments. They saw their employer as culpable for dismal working conditions, lack of vital equipment, administrative mismanagement and salaries out of kilter with other State professionals - and striking as their last resort to protect patients in the long term.2

Create trouble-shootingdoctor commission

Mokgokong was happy to wade into the ethical debate, much of which focused on the government refusing to sign a minimum service level agreement that would set out protocols for patient protection during labour disputes - and enable legal strikes. 'My answer is for doctors to get out of the joint bargaining chamber [Public Health and Social Development Sectoral Bargaining Chamber]. We deserve a special dispensation. The whole world does this. While I don't have a specific model in mind, if we had a sort of commission ... all that needs doing is [to provide] good contact between the profession and such a commission, on which members of the profession must serve. It can deal proactively with issues specific to the profession like determination of fees. They [fees] shouldn't depend on South Africa's annual GDP or inflation. It must be looked at internationally and compared with equivalent countries. We need to deal proactively and quickly with these issues ... there's no need to strike.'

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Mokgokong said the 'ethics of humanity' were such that when doctors were angry, they did not let people die. 'You don't strike, no matter how angry you are - we now have a minister who seems to be a listening minister, so things are looking up. I must be honest, in the past things were not great. The worry is who takes care of doctors' complaints? That's where we as the HPCSA can fulfil our mandate to advise and/or lobby the minister. That strike was unprecedented - I mean there were certainly grievances in the apartheid era. How do you strike when Mkhize dies because you're angry with Strydom in Parliament? That argument still holds today. You cannot bargain with innocent lives, even when some MPs don't use public health services.'

In his inaugural HPCSA presidential speech Mokgokong cited Finance Minister Pravin Gordhan, publicly labelling the health and education sectors as 'cash cows for fraudulent provincial administrators'. He told Izindaba that money was being wasted in terms of the Public Finance Management Act via irregular and unauthorised expenditure.

Deal with doctors' working environment

'We in Health have already picked this up and run to the minister, saying that teaching hospitals have to come out of the hands of provincial governments and put into national's hands. When money goes missing everything comes to a halt. Tertiary hospitals attached to universities are national, not provincial assets. The playing fields are not equal and professionals move to provinces where things are done better.'

Asked what his priority as president would be, Mokgokong said all Council stakeholders were important, 'but I must start with the doctors themselves. Many of us are with the SA Medical Association and experience the problems expressed by them. We have to improve the conditions of doctors so they can be in a happier environment and produce better work. The Act prescribes that we protect the community and health care delivery has to be improved.'

Asked if he planned any innovations to lure doctors back from among the legions who've left South Africa, Makgokong said measures like moratoriums on HPCSA re-registration fees were ineffective and at best 'cut off our noses to spite our faces' financially. 'Every year the HPCSA faces an increasing bill of arrears (non-payment of fees) and a lot of professionals abscond. I think incentives should be at the operational level, in the working environment. Let's get that right.'

The newly elected Council sat for the first time on 1 March this year and has 6 months to craft a strategic plan that is in alignment with the amended Health Professions Act. Mokgokong seems determined to chip away at doctors' negative perceptions of the HPCSA, but still has a mountain to climb.